- Email: [email protected]
Effect of aromatherapy on post-partum complications: A systematic review
Complementary Therapies in Clinical Practice 35 (2019) 290–295
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Effect of aromatherapy on post-partum complications: A systematic review a
b
c
d
Khadije Rezaie-Keikhaie , Marie Hastings-Tolsma , Salehoddin Bouya , Fahime Shojaei Shad , Mahdieh Sarie, Maryam Shoorvazif,∗, Zeinab Younes Baranie, Abbas Balouchig
T
a
Zabol Medicinal Plants Research Center, Zabol University of Medical Sciences, Zabol, Iran Nurse Midwifery, Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA Clinical Immunology Research Center, Ali-ebne Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran d MSC in Nursing, Nursing and Midwifery School, Zabol University of Medical Sciences, Zabol, Iran e Student Research Committee, Nursing and Midwifery School, Zabol University of Medical Sciences, Zabol, Iran f Department of Nursing, School of Nursing, Neyshabur University of Medical Sciences, Neyshabur, Iran g Student Research Committee, Nursing and Midwifery School, Iran University of Medical Sciences, Tehran, Iran b c
ARTICLE INFO
ABSTRACT
Keywords: Aromatherapy Essential oils Post-partum symptoms Systematic review
Introduction: and purpose: Aromatherapy is a known popular method to reduce the symptoms of various physiologic processes and diseases. The aim of the study was to determine whether aromatherapy improves symptoms commonly experienced by women during the postpartum period. Methods: In the present systematic review, four international databases (PubMed, Google Scholar, Web of Science, and Scopus) were searched from inception of databases through August 2018. References for each study were manually reviewed to ensure that relevant works were included. Results: Thirty-four (34) articles were identified with 17 studies meeting eligibility criteria and included a total of 1400 women using a variety of aromatherapies. Results demonstrated that aromatherapy can improve symptoms commonly experienced in post-partum period, including depression, stress, pain, anxiety, and fatigue. Conclusion: There are therapeutic effects in use of aromatherapy during the post-partum period. Aromatherapy, however, should be used with caution as safety concerns have not been conclusively demonstrated.
1. Background The postpartum period is considered as a crucial time associated with various physical and emotional symptoms including pain, impaired sleep quality, stress, anxiety, and fatigue [1–4]. In the postpartum period, more attention is paid to the neonates, and mothers are particularly less evaluated for post-partum symptoms. Screening, diagnosis, and treatment of postpartum symptoms are also essential. The results of studies show that along with treatment of physical symptoms during this period, social support is necessary for improvement of psychological symptoms [5,6]. Various studies indicate that the postpartum period is often associated with having “postpartum blues,” which include temporary transient symptoms, the development of depression and anxiety, as well as feelings of forgetfulness, irritability, headache, and dizziness [7,8]. The prevalence of these symptoms range from 25% to 85% varying in different countries [9–11]. Available treatments for common post-partum symptoms include complementary and alternative therapy approaches - though they often lack evidence for safety and efficacy [12], and complication-specific
∗
pharmacologic therapies [13,14]. Both approaches are designed to minimize postpartum morbidity and mortality and improve quality of life. The use of complementary and alternative therapies has become very popular in recent years [15,16]. Complementary and alternative therapies are popular methods among pregnant women as well. Research from varied countries demonstrate rates of aromatherapy use among pregnant women ranging from 13 to 78% [17]. In addition, studies indicate that most women use at least one complementary therapy during pregnancy [18–20]. Aromatherapy is one complementary and alternative therapy that is very popular considering its ease of use and availability [21]. Aaromatherapy medicinally applies aromatic substances or essential oils to effect health and mood. Essential oils are volatile oils obtained from raw vegetable material through a process of distillation with water or steam, or by dry distillation and are known to have antiseptic, antimicrobial, antiviral, antifungal, and antioxidant properties [22]. Some of the plants used in the creation of essential oils include rosemary, jasmine, rose, tangerine, patchouli, cinnamon, and lavender. Aromatherapy is typically used through topical application or inhalation
Corresponding author. Nursing and Midwifery School, 15 Khordad S, Neyshabur, Iran. E-mail addresses: [email protected], [email protected] (M. Shoorvazi).
https://doi.org/10.1016/j.ctcp.2019.03.010 Received 11 December 2018; Received in revised form 21 February 2019; Accepted 12 March 2019 1744-3881/ © 2019 Elsevier Ltd. All rights reserved.
Complementary Therapies in Clinical Practice 35 (2019) 290–295
K. Rezaie-Keikhaie, et al.
Fig. 1. Study selection process.
symptoms and quality of life. Findings are potentially of use to health professionals and women where efforts are made to reduce symptoms and improve quality of life.
[23]. Topical application through use of massage oils, or bath and skin care products, allows for absorption through the skin. Inhalation allows for oil evaporation into the air through use of a diffuser, spray or droplets, then breathing in the product [22]. When inhaled, the essential oil molecules are sensed by olfactory epithelium and a neural impulse is generated. This neural impulse reaches the olfactory bulb, passes through the olfactory nerve, reaches the limbic region, and stimulates the limbic system of the brain. Essential oils penetrate the skin, enter the bloodstream and the immune system, and release endorphins, improve oxygenation, and nourish cells and tissues, leading to physical and emotional relaxation and a good feeling, because they can have beneficial effects on physiological and psychological processes [24]. Inhaled aromatherapy exerts its effects as physical and mental improvement and stabilization of emotions in persons; these effects can lead to therapeutic effects including reduction in anxiety, depression, pain, spasm, muscle cramp, and fatigue, and improvement of sleep quality [25]. There is a large body of anecdotal evidence regarding the safety and efficacy of essential oils and, while many have been shown to be safe when used as directed, the products are not regulated by the Food and Drug Administration in the United States [26]. Caution is warranted regarding use to minimize possible risks and benefits, particularly in lactating women during the postpartum period where newborn impacts are unknown. Various studies have shown that the aromatherapy is used during pregnancy and postpartum to treat and improve various symptoms such as depression and anxiety, as well as quality of life [12,27,28]. Nevertheless, various studies differ in terms of method, type, amount, and duration of use of varied aromas, and there is a contradiction between results which lead to different results. Therefore, the aim of the present study was to determine the effect of aromatherapy, as an evidence-based, cost-effective and available treatment, on postpartum
2. Methods 2.1. Search strategy Four (4) databases were searched from inception of databases August 2018. These databases included PubMed, Google Scholar, Web of Science, and Scopus. Keywords used included “inhalation aromatherapy” AND “postpartum complication” AND “essential oil” AND “massage aromatherapy.” References for each identified study were manually reviewed to ensure that relevant works were not missed. Inclusion criteria were published, full-length, peer-reviewed studies written in English. The sample population had to comprise postpartum women and use valid and reliable measures to assess outcomes. We excluded abstracts, dissertations and theses, qualitative studies, studies of low methodological quality, and studies where aromatherapy was not the primary focus. Ethical approval was not required for this study since no primary data was being collected. 2.2. Study selection and quality assessment PRISMA guidelines (2009) were used to assess intervention and evaluation studies [29]. Article titles, abstracts and finally full content of the articles were evaluated by two of the researchers (A.B and M.S) to determine the extent to which each article met the inclusion criteria and ensure high inter-rater reliability. Duplicates were removed prior to the analysis. The data extracted included study characteristic (Design, Sample, Quality Assessment), interventions details (time, frequency, 291
Randomized clinical 89 trial PPD 2–10 Randomized control 80 trial PPD 6-8
Behmanesh, F.(2011) [34]
292
Randomized clinical 158 trial PPD 0-8
Randomized clinical trial Randomized clinical trial Randomized clinical trial Quasi-experimental
Randomized clinical 96 trial PPD 0-8
Randomized clinical 96 trial PPD 0-8
Keshavarz Afshar, M. (2015) [44]
Kianpour, M.(2016) [28]
Metawie, M. (2015) [45]
Mirghafourvand, M. (2016) [38]
Mirghafourvand, M. (2017) (25)
140 PPD 105 PPD 35 PPD 100 PPD 0-1
NR
0-6
1-3
36 PPD 2
Vakiliyan, K. (2008) [40] Randomized clinical 120 trial PPD 0-2
Lane, B.(2012) [37]
Kianpour, M.(2018) [36]
Quasi-experimental
Imura, M.(2006) [48]
141 PPD 0-6
Randomized Controlled Trial
Effati-Daryani, F.(2017) [27]
28 PPD 0-18
Pilot study
34 PPD 1-7
Conrad, P.(2012) [43]
Chen, S.L. (2015) [35]
Quasi-experimental one-group
Asazawa, K. (2018) [46]
34 PPD 1-7
Quasi-experimental one-group
Asazawa, K. (2017) [47]
Primary Results
Inhalation aromatherapy lavender
Drink aroma oil Orange
Drink aroma oil Orange
Inhalation aromatherapy using lavender essence oil 10%, 4 drops per session, four times a week before sleeping for 5 min at eight weeks. Inhalation aromatherapy using 3 drops of Lavender scent every day for 4 weeks. Inhalation aromatherapy using 7 drops of Lavender and rose scents every day for 6 weeks. Inhalation aromatherapy using peppermint spirits for between 2 and 5 min. Inhalation aromatherapy using 1 cc of lavender oil via an oxygen facemask, three days per week, for four months. Drink a glass of water containing 10 drops of orange peel essential oil, 3 times a day for eight weeks. Drink a glass of water containing 10 drops of orange peel essential oil, 3 times a day for eight weeks. Bath aromatherapy using 5–10 drops of lavender essence oil twice a day for five days.
Inhalation/Massage Inhalation and massage aromatherapy using 8 aromatherapy lavender and Rose drops blend 2% essential oil of lavender and rose, twice a week, for four weeks. Massage aromatherapy lavender Massage aromatherapy using 2 gr Lavender cream every night 1.5 h before bedtime for six weeks. Massage aromatherapy lavender Massage aromatherapy using 10 drops Lavender and Neroli per 100 ml once for 30 min.
Bath aromatherapy lavender and Bath aromatherapy using 10 drops lavender and olive oil essence oil 10% in five liters of warm water twice a day in ten days. Inhalation/drink aromatherapy Inhalation aromatherapy and ingest a glass of lavender hot water containing 2 gr steeped lavender one a day before bedtime for two weeks.
Quality Assessment Score 1.Scale 2.Score or judgment
Positive effect on episiotomy ulcers
No positive effect on depression and anxiety
Positive effect on sleep quality
Positive effect on post-Caesarean incision pain
Positive effect on stress, anxiety and depression Positive effect on postpartum depression Positive effect on nausea
Positive effect on quality of sleep
(continued on next page)
1.Jadad 2.4
1.Jadad 2.3
1.Jadad 2.5
1.Jadad 2.3 1.Jadad 2.5 1.Jadad 2.5 1.JBI 2.included
1.Jadad 2.4
1.JBI 2.included
1.Jadad 2.4
Positive effect on stress, anxiety, depression, Positive effect on anxiety, maternity blues, mood, and feeling toward baby
1.JBI 2.included
1.Jadad 2.5
1.Jadad 2.3
1.JBI 2.Include
Decrease anxiety and depression.
Positive effect on sleep quality; fatigue (p = 0.01), depression (p = 0.03 and improving maternal infant bonding (p = 0.04)
Positive effect on pain and postpartum healing
Massage aromatherapy lavender, Massage aromatherapy using one of five types of No effect on fatigue; positive effect on ylang-ylang, citron, rosewood, essential aroma oil (pure lavender, ylang-ylang, relaxation and sweet orange citron, rosewood, and sweet orange), Once for 5 min.
Episiotomy ulcers, VAS Bath aromatherapy lavender
Depression and Anxiety, STAI
sleep quality, PSQI
Intervention and dose
Massage aromatherapy lavender, Massage aromatherapy using one of five types of Positive effect on fatigue and relaxation 1.JBI ylang-ylang, citron, rosewood, essential aroma oil (pure lavender, ylang-ylang, where citron and sweet orange used 2.Include and sweet orange citron, rosewood, and sweet orange), Once for (p < 0.05) 5 min.
Type of Aromatherapy 2.dose
Inhalation aromatherapy lavender Inhalation aromatherapy lavender and Rose water Inhalation aromatherapy Peppermint Post Caesarean Incision Inhalation aromatherapy Pain, MJPOM, VAS lavender
Stress, anxiety and depression, DASS-21 Postpartum Depression, HADS Nausea, Nausea Scale
Maternity Blues, STAIAnxiety, POMS Mood, MBS feeling toward baby, FBS quality of sleep, PTSQI
Stress, anxiety and depression, DASS-21
Fatigue, subjective symptoms scale Relaxation, subjective sense of relaxation scale Fatigue, subjective symptoms scale Relaxation, (subjective sense of relaxation scale) Pain, VAS Postpartum healing, REEDA Sleep quality, PSQS Fatigue, EPDS Depression, PFS Improving maternal infant attachment, PBQ Anxiety, EPDS Depression, GAD-7
Sample Size Outcome Measures
Study Design
First Author (Year)
Table 1 Description of the study characteristics, outcome, measurement, interventions and results.
K. Rezaie-Keikhaie, et al.
Complementary Therapies in Clinical Practice 35 (2019) 290–295
Complementary Therapies in Clinical Practice 35 (2019) 290–295
Stress, DASS Prolactin level, ELISA Widyawati, M.(2016) [42]
Key = VAS: Visual Analogue Scale, REEDA: Redness, edema, Ecchymosis, Discharge, Approximation; PSQS: Postpartum Sleep Quality Scale; PFS: Postpartum Fatigue Scale; EPDS: Edinburgh Postnatal Depression Scale; PBQ: Postpartum Bonding Questionnaire; GAD-7: Generalized Anxiety Disorder 7-item; DASS-21: The Depression, Anxiety and Stress Scale - 21 Items; STAI: The State-Trait Anxiety Inventory; POMS: Profile of mood states scale; PTSQI: Pittsburgh Sleep Quality Index; HADS: Hospital Anxiety and Depression Scale; MJPOM: Modified Johanson Pain-O-Meter; ELISA: enzyme-linked immunosorbent assay; PPD: postpartum day.
1.Jadad 2.4 1.Jadad 2.5 Inhalation aromatherapy using 5 drops of No positive effect on episiotomy pain lavender essence oil three times. Inhalation/massage aromatherapy using 3 drops Positive effect on stress, and prolactin of Jasmine, once a week for four weeks. level Inhalation aromatherapy lavender Inhalation/Massage aromatherapy Jasmine Intensity of pain, VAS
Randomized clinical 56 trial PPD 0-2 Randomized clinical 52 trial PPD 7-28 Vaziri, F.(2017) [41]
First Author (Year)
Table 1 (continued)
Study Design
Sample Size Outcome Measures
Type of Aromatherapy 2.dose
Intervention and dose
Primary Results
Quality Assessment Score 1.Scale 2.Score or judgment
K. Rezaie-Keikhaie, et al.
and dose), and results. Quality Assessment of each study was conducted using the Jadad scale whose rating criteria take into account randomization, double blinding, and withdrawals or dropouts [30]. The quality of quasi-experimental studies was assessed using the Joanna Briggs Institute (JBI) quasi-experimental appraisal tool [31]. Each article was independently rated by two of the researchers (K.RK, A, B); disagreements were discussed with third person until consensus was reached. Studies were deemed to be of sufficient quality if they achieved an average score of 3–5 on the JBI instrument [32], and yes answer in 3 of 6 items on the Jadad scale [33]. 3. Results 3.1. Study selection A total of 191 articles were retrieved from the search of databases; 35 from PubMed, 31 from Google Scholar, 14 from Web of Science, and 111 from Scopus. Of the 151 non-duplicated studies in the title and abstract screening process, 117 were excluded because they had unrelated titles and abstracts. Of the remaining 34 studies, 17 met the eligibility criteria. Of the 17 excluded studies, three were review, one was qualitative, six did not have the full text, three were not in English and four did not meet quality requirements for inclusion (see Fig. 1). 3.2. Study characteristics A total of 17 studies that were carried out on 1400 postpartum women entered the final phase. Of these, most of them were clinical trials (n = 12) [12,27,28,34–42]. The sample size across studies ranged from 28 to 158. All studies had low bias risk. Table 1 demonstrates the included studies, design, sample size, measures, type of intervention, primary outcomes, and quality assessment score. 3.3. Main results 3.3.1. Type of interventions Aromatherapy interventions used across studies included inhalation aromatherapy (n = 9) [28,35–37,41–45], aromatherapy massage (n = 6) [27,42,43,46–48], bath with aroma (n = 2) [34,40], and consumption of aroma-containing beverages (n = 2) [38,39]. Interventions were carried out separately or in a combined manner. The aromas examined included lavender (n = 13) [27,28,34–36,40–44,46–48], orange (n = 4) [38,39,46,47], and rose (n = 4) [36,43,46,47]. 3.3.2. Interventions procedures Six studies investigated aromatherapy massage interventions with 3–10 drops used for 5 min to 1.5 h ranging from one day to 6 weeks. In the 9 studies that investigated the various inhalation aromatherapy interventions, 3 to 8 drops were used from 2 to 5 min (three times a day, for one week up to four months). Another four studies investigated other aromatherapies with two studies examining bath use of where 10 lavender drops were added to 5 L of warm water; individuals took a bath twice a day for 10 days. In another intervention, 10 orange aroma drops were dissolved in a glass of warm water and ingested three times a day for 8 weeks. 3.4. Effect of aromatherapy on common postpartum symptoms The 17 studies included in this systematic review investigated the effect of aromatherapy on commonly experienced postpartum symptoms. The most commonly reported symptoms and outcomes included depression (n = 6) [27,28,35,36,39,43], fatigue (n = 3) [35,46,47], and stress (n = 3) [27,28,42]. Reviewing the effect of aromatherapy on postpartum symptoms (outcomes) showed that the aromatherapy had a positive effect on depression (n = 5) [27,28,35,36,43], fatigue (n = 3) [35,46,47], stress (n = 3) [27,28,42], anxiety (n = 2) [27,28], 293
Complementary Therapies in Clinical Practice 35 (2019) 290–295
K. Rezaie-Keikhaie, et al.
relaxation (n = 1) [47], pain (n = 2) [34,45], sleep quality (n = 3) [35,38,44], episiotomy pain (n = 1) [41], postpartum healing (n = 1) [34], nausea (n = 1) [37], prolactin level (n = 1) [42], episiotomy ulcers (n = 1) [40], maternity blues, mood, and feeling toward baby (n = 1) [48], and improving maternal-infant attachment (n = 1) [35]. Aromatherapy use had no significant effect on fatigue, depression or anxiety in one study [39], or on relaxation in another [46]. In order to ensure the safety of aromatherapy, psychiatrists were present along with patients during the intervention in some studies.
postpartum complications. There were also differences in the defined postpartum period with studies ranging from one day to 8 weeks, and postpartum women who had experienced both surgical (i.e., Caesarean, episiotomy) and normal physiologic birth were included and potentially biasing results. Finally, one study (16) examined use of aromas across pregnancy and postpartum periods creating potential bias where treatment was prolonged. Despite the current limitations, this is the first known systematic review that investigates the effects of aromatherapy on common postpartum complications. The promising results should prompt further larger and methodologically sound research.
4. Discussion This is the first known systematic review or meta-analysis specifically investigating the effect of aromatherapy on postpartum symptoms. Work reported here determined the effect of aromatherapy on postpartum symptoms from inception of databases to August 2018. A total of 17 studies were examined and included 1400 women. The aromatherapy interventions in various studies were based on inhalation aromatherapy, aromatherapy massage, bath with aroma, and aroma ingestion (drinking). Findings demonstrate that aromatherapy improves or diminishes commonly experienced postpartum symptoms including depression, fatigue, stress, anxiety, relaxation, pain, sleep quality, episiotomy pain, postpartum healing, nausea, altered prolactin levels, episiotomy ulcers, maternity blues, mood lability, and feelings toward baby. It was interesting to note that lavender was the most commonly used essential oil and likely explains the improvement of the identified post-partum symptoms. Lavendar is known to contain camphor, terpinen-4-ol, linolool, linalyl aetate, beta-ocimene, and 1,8-cineole [23]. These constituents are known to depress the central nervous system, have sedative effects, and marked narcotic-like actions which can reduce anxiety and sleep difficulties, and improve a sense of well-being [23,49,50]. Constituents have also been shown to promote new cell growth, reduce skin problem, reduce painful muscles, and improve immune functioning. There were three studies (25, 27, 32) demonstrating that aromatherapy has no effect on fatigue, pain, depression or anxiety. Asazawa and colleagues (33) conducted a pilot study examining the effect of massage aromatherapy on postpartum fatigue and relaxation and found two massage oils provided significant reduction in fatigue and increased relaxation with use of citron and sweet orange oils (p < 0.05). Study replication found no significant differences. Since no other included study examined use of these particular aromas, further study is warranted, also considering the other aspects of aromatherapy can be help. While several of the studies utilized differences in dosage and methodology, findings from this systematic review are consistent with systematic review studies on the effects of aromatherapy on depression in populations of chronic patients [51], psychological symptoms in post-menopausal women [52], anxiety in chronic patients [24], pain relief in chronic patients [26], depression [53], sleep quality [54], and nausea and vomiting of women during pregnancy [54]. Safety in the present study was confirmed because essential oils were obtained from standard companies. The efficacy and presumed safety of raw materials was further confirmed through pilot use in previous studies of case series [55]. Finally, there were some limitations to the work presented here. The most important limitation of the present study is that while all studies utilized aromatherapy, different aromas were used and at different doses which it is an important barrier to wide use of study results. A few studies failed to give precise details regarding the interventions mentioned making it difficult to analyze the works with greater rigor. These differences made it impossible to conduct a meta-analysis to more precisely determine the effect of aromas on postpartum symptoms. Additionally, several of the studies had small sample sizes with failure to report power calculations. Both nulligravid and multigravid women were included with potentially different experiences of common
5. Conclusion Results from this systemic review demonstrate that aromatherapy is effective as an inexpensive, easy-to-use, fast-acting, and holistic method to improve common postpartum symptoms such as nausea, postpartum blues, depression, and mood lability, as well as anxiety, stress, fatigue, pain – including episiotomy pain, and episiotomy ulcers. Further, aromatherapy improves postpartum relaxation, sleep quality, healing, prolactin levels, and feelings toward the baby. Despite the great benefits of aromatherapy in the postpartum period, the perfumes should be used with caution and after evaluating their safety due to the mentioned limitations. Given the limited number of articles in this area, further studies are also suggested into the effects of aromatherapy on pregnant women. Authors’ contribution Khadije Rezaie-Keikhaie and Maryam Shoorvazi: study design and conceptualization; Maryam Shoorvazi, Zeinab Younes Barani and Fahime Shojaei Shad: Search strategy and data collection; Mahdieh Sari and Abbas Balouchi: data analysis and interpretation; Marie HastingsTolsma, Khadije Rezaie-Keikhaie, Abbas Balouchi, and Salehoddin Bouya: manuscript writing; Marie Hastings-Tolsma, Khadije RezaieKeikhaie, Maryam Shoorvaz: study supervision. Financial conflicts of interest None declared. Funding/support None declared. Acknowledgments The author wishes to thank the nursing research center and the deputy of research and technology at Zabol University of Medical Sciences. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ctcp.2019.03.010. References [1] P. Berens, Overview of the Postpartum Period: Physiology, Complications, and Maternal Care, (2018). [2] O. Stephansson, A. Sandström, G. Petersson, A.K. Wikström, S. Cnattingius, Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period, BJOG An Int. J. Obstet. Gynaecol. 123 (4) (2016) 608–616. [3] B.W. Prick, D. Bijlenga, A.G. Jansen, K.E. Boers, S.A. Scherjon, C.M. Koopmans, M.G. van Pampus, M.-L. Essink-Bot, D.J. van Rhenen, B.W. Mol, Determinants of health-related quality of life in the postpartum period after obstetric complications, Eur. J. Obstet. Gynecol. Reprod. Biol. 185 (2015) 88–95.
294
Complementary Therapies in Clinical Practice 35 (2019) 290–295
K. Rezaie-Keikhaie, et al.
[30] H.D. Clark, G.A. Wells, C. Huët, F.A. McAlister, L.R. Salmi, D. Fergusson, A. Laupacis, Assessing the quality of randomized trials: reliability of the Jadad scale, Contr. Clin. Trials 20 (5) (1999) 448–452. [31] C. Tufanaru, Z. Munn, E. Aromataris, J. Campbell, L. H (Eds.), Systematic Reviews of Effectiveness, 2017 (Chapter 3), https://reviewersmanual.joannabriggs.org/. [32] C. Tufanaru, Z. Munn, E. Aromataris, J. Campbell, L. H, Chapter 3: systematic reviews of effectiveness, in: E. Aromataris, Z. Munn (Eds.), Joanna Briggs Institute Reviewer's Manual. 2017 https://reviewersmanual.joannabriggs.org. [33] A.R. Jadad, R.A. Moore, D. Carroll, C. Jenkinson, D.J. Reynolds, D.J. Gavaghan, H.J. McQuay, Assessing the quality of reports of randomized clinical trials: is blinding necessary? Contr. Clin. Trials 17 (1) (1996) 1–12. [34] F. Behmanesh, M. Tofighi, M.A. Delavar, M. Zeinalzadeh, A.A. Moghadamnia, S. Khafri, A clinical trial to compare the effectiveness of lavender essential oil and olive oil at healing postpartum mother's perinea, HealthMED 5 (6) (2011) 1512–1516. [35] S.L. Chen, C.H. Chen, Effects of lavender tea on fatigue, depression, and maternalinfant attachment in sleep-disturbed postnatal women, Worldviews Evidence-Based Nurs. 12 (6) (2015) 370–379. [36] M. Kianpour, F. Moshirenia, G. Kheirabadi, G. Asghari, A. Dehghani, A. DehghaniTafti, The effects of inhalation aromatherapy with rose and lavender at week 38 and postpartum period on postpartum depression in high-risk women referred to selected health centers of Yazd, Iran in 2015, Iran. J. Nurs. Midwifery Res. 23 (5) (2018) 395–401. [37] B. Lane, K. Cannella, C. Bowen, D. Copelan, G. Nteff, K. Barnes, M. Poudevigne, J. Lawson, Examination of the effectiveness of peppermint aromatherapy on nausea in women post C-section, J. Holist. Nurs. : Off. J. Am. Holistic Nurses' Assoc. 30 (2) (2012) 90–104 quiz 105-6. [38] M. Mirghafourvand, S.M.A. Charandabi, S. Hakimi, L. Khodaie, M. Galeshi, Effect of orange peel essential oil on postpartum sleep quality: a randomized controlled clinical trial, Eur. J. Integr. Med. 8 (1) (2016) 62–66. [39] M. Mirghafourvand, S.M.A. Charandabi, S. Hakimi, L. Khodaie, M. Galeshi, The effect of orange peel essential oil on postpartum depression and anxiety: a randomized controlled clinical trial, Iran. Red Crescent Med. J. 19 (2) (2017). [40] K. Vakilian, M. Atarha, The effect of lavender in care of postpartum episiotomy wounds, J. Shahrekord Univ. Med. Sci. 10 (2008). [41] F. Vaziri, M. Shiravani, F.S. Najib, S. Pourahmad, A. Salehi, Z. Yazdanpanahi, Effect of lavender oil aroma in the early hours of postpartum period on maternal pains, fatigue, and mood: a randomized clinical trial, Int. J. Prev. Med. 8 (2017) 29. [42] M.N. Widyawati, S. Hadisaputro, A. Anies, A. Soejoenoes, Effect of massage and aromatherapy on stress and prolactin level among primiparous puerperal mothers in Semarang, central Java, Indonesia, Belitung Nursing Journal 2 (4) (2016). [43] P. Conrad, C. Adams, The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman - a pilot study, Complement. Ther. Clin. Pract. 18 (3) (2012) 164–168. [44] M. Keshavarz Afshar, Z.B. Moghadam, Z. Taghizadeh, R. Bekhradi, A. Montazeri, P. Mokhtari, Lavender fragrance essential oil and the quality of sleep in postpartum women, Iran. Red Crescent Med. J. 17 (4) (2015) 1–7. [45] M.A.-H. Metawie, H. Amasha, R.A. Abdraboo, S.E. Ali, Effectiveness of aromatherapy with lavender oil in relieving post Caesarean Incision pain, J. Surg. 3 (2–1) (2015) 8–13. [46] K. Asazawa, Y. Kato, R. Koinuma, N. Takemoto, S. Tsutsui, Effectiveness of aromatherapy treatment in alleviating fatigue and promoting relaxation of mothers during the early postpartum periaod, Open J. Nurs. 8 (03) (2018) 196. [47] K. Asazawa, Y. Kato, A. Yamaguchi, A. Inoue, The effect of aromatherapy treatment on fatigue and relaxation for mothers during the early puerperal period in Japan: a pilot study, Int. J. Commun. Based Nurs. Midwifery 5 (4) (2017) 365–375. [48] M. Imura, The psychological effects of aromatherapy-massage in healthy postpartum mothers, J. Midwifery Women's Health 51 (2) (2006) e21–e27. [49] S. Kim, H.-J. Kim, J.-S. Yeo, S.-J. Hong, J.-M. Lee, Y. Jeon, The effect of lavender oil on stress, bispectral index values, and needle insertion pain in volunteers, J. Altern. Complement. Med. 17 (9) (2011) 823–826. [50] P.H. Koulivand, M. Khaleghi Ghadiri, A. Gorji, Lavender and the nervous system, evid.-based complement, Altern. Med. 2013 (2013). [51] V. Yim, A.K. Ng, H.W. Tsang, A.Y. Leung, A review on the effects of aromatherapy for patients with depressive symptoms, J. Altern. Complement. Med. 15 (2) (2009) 187–195. [52] M. Babakhanian, M. Ghazanfarpour, L. Kargarfard, N. Roozbeh, L. Darvish, T. Khadivzadeh, F.R. Dizavandi, Effect of aromatherapy on the treatment of psychological symptoms in postmenopausal and elderly women: a systematic review and meta-analysis, J. Menopausal Med. 24 (2) (2018) 127–132. [53] D.I. Sánchez-Vidaña, S.P.-C. Ngai, W. He, J.K.-W. Chow, B.W.-M. Lau, H.W.H. Tsang, The effectiveness of aromatherapy for depressive symptoms: a systematic review, Evid.-Based Complement, Altern. Med. 2017 (2017). [54] E. Hwang, S. Shin, The effects of aromatherapy on sleep improvement: a systematic literature review and meta-analysis, J. Altern. Complement. Med. 21 (2) (2015) 61–68. [55] T. Dunning, Aromatherapy: overview, safety and quality issues, OA Altern. Med. 1 (1) (2013) 6.
[4] X. Liu, E. Agerbo, J. Li, S. Meltzer-Brody, V. Bergink, T. Munk-Olsen, Depression and anxiety in the postpartum period and risk of bipolar disorder: a Danish nationwide register-based cohort study, J. Clin. Psychiatry 78 (5) (2017) e469–e476. [5] I. Brockington, Postpartum psychiatric disorders, Lancet 363 (9405) (2004) 303–310. [6] D.K. Gjerdingen, K.M. Chaloner, The relationship of women's postpartum mental health to employment, childbirth, and social support, J. Fam. Pract. 38 (5) (1994) 465–473. [7] S. Seth, A.J. Lewis, M. Galbally, Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review, BMC Pregnancy Childbirth 16 (1) (2016) 124. [8] A.R. Gobinath, R.J. Richardson, C. Chow, J.L. Workman, S.E. Lieblich, A.M. Barr, L.A. Galea, Voluntary running influences the efficacy of fluoxetine in a model of postpartum depression, Neuropharmacology 128 (2018) 106–118. [9] P. Vigano, L. Corti, N. Berlanda, Beyond infertility: obstetrical and postpartum complications associated with endometriosis and adenomyosis, Fertil. Steril. 104 (4) (2015) 802–812. [10] D. Ehrmann Feldman, É. Vinet, M.-P. Sylvestre, B. Hazel, C. Duffy, A. Bérard, G. Meshefedjian, S. Bernatsky, Postpartum complications in new mothers with juvenile idiopathic arthritis: a population-based cohort study, Rheumatology 56 (8) (2017) 1378–1385. [11] E. Kang, R. Sugarman, H. Ramadan, A. Mueller, S. Shahul, J.L. Perdigao, D.J. Louis, R. Narcisse, H. Sannon, L. Magee, Prevalence, risk factors and associated complications of postpartum hypertension in rural Haiti, Pregnancy hypertension 10 (2017) 135–142. [12] M.K. Afshar, Z.B. Moghadam, Z. Taghizadeh, R. Bekhradi, A. Montazeri, P. Mokhtari, Lavender fragrance essential oil and the quality of sleep in postpartum women, Iran. Red Crescent Med. J. 17 (4) (2015). [13] A.D. Mackeen, R.E. Packard, E. Ota, L. Speer, Antibiotic regimens for postpartum endometritis, Cochrane Database Syst. Rev. (2) (2015). [14] B. Shulman, R. Dueck, D. Ryan, G. Breau, I. Sadowski, S. Misri, Feasibility of a mindfulness-based cognitive therapy group intervention as an adjunctive treatment for postpartum depression and anxiety, J. Affect. Disord. 235 (2018) 61–67. [15] S. Bouya, S. Ahmadidarehsima, M. Badakhsh, A. Balouchi, Effect of Aromatherapy Interventions on Hemodialysis Complications: A Systematic Review, Complementary Therapies in Clinical Practice, (2018). [16] A. Balouchi, G. Mahmoudirad, M. Hastings-Tolsma, S.A. Shorofi, H. Shahdadi, A. Abdollahimohammad, Knowledge, Attitude and Use of Complementary and Alternative Medicine Among Nurses: A Systematic Review, Complementary Therapies in Clinical Practice, (2018). [17] H.G. Hall, D.L. Griffiths, L.G. McKenna, The use of complementary and alternative medicine by pregnant women: a literature review, Midwifery 27 (6) (2011) 817–824. [18] L. Gaffney, C.A. Smith, The Views of Pregnant Women towards the Use of Complementary Therapies and Medicines, (2004). [19] C.O. Ong, L.Y. Chan, P.B. Yung, T.N. Leung, Use of traditional Chinese herbal medicine during pregnancy: a prospective survey, Acta Obstet. Gynecol. Scand. 84 (7) (2005) 699–700. [20] H. Skouteris, E.H. Wertheim, S. Rallis, S.J. Paxton, L. Kelly, J. Milgrom, Use of complementary and alternative medicines by a sample of Australian women during pregnancy, Aust. N. Z. J. Obstet. Gynaecol. 48 (4) (2008) 384–390. [21] A. Balouchi, M. Rahnama, M. Hastings-Tolsma, M.M. Shoja, E. Bolaydehyi, Knowledge, attitude and use of complementary and integrative health strategies: a preliminary survey of Iranian nurses, J. Integr. Med. 14 (2) (2016) 121–127. [22] C. Nordqvist, Aromatherapy: what you need to know, https://www. medicalnewstoday.com/articles/10884.php, (2017) , Accessed date: 21 February 2019. [23] B. Ali, N.A. Al-Wabel, S. Shams, A. Ahamad, S.A. Khan, F. Anwar, Essential oils used in aromatherapy: a systemic review, Asian Pac. J. Trop. Biomed. 5 (8) (2015) 601–611. [24] Y.-L. Lee, Y. Wu, H.W. Tsang, A.Y. Leung, W. Cheung, A systematic review on the anxiolytic effects of aromatherapy in people with anxiety symptoms, J. Altern. Complement. Med. 17 (2) (2011) 101–108. [25] M.J. Kim, E.S. Nam, S.I. Paik, The effects of aromatherapy on pain, depression, and life satisfaction of arthritis patients, J. Korean Acad. Nurs. 35 (1) (2005) 186–194. [26] S.E. Lakhan, H. Sheafer, D. Tepper, The Effectiveness of Aromatherapy in Reducing Pain: a Systematic Review and Meta-Analysis, Pain Research and Treatment 2016, (2016). [27] F. Effati Daryani, S.M.A. Charandabi, S. Zarei, A. Mohammadi, M. Mirghafourvand, Effect of lavender cream with or without footbath on anxiety, stress and depression of women in postpartum: a clinical randomized controlled trial, Iran, J. Obstet. Gynaecol. India 20 (10) (2017) 52–61. [28] M. Kianpour, A. Mansouri, T. Mehrabi, G. Asghari, Effect of lavender scent inhalation on prevention of stress, anxiety and depression in the postpartum period, Iran. J. Nurs. Midwifery Res. 21 (2) (2016) 197–201. [29] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, PLoS Med. 6 (7) (2009) e1000097.
295
Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: www.elsevier.com/locate/ctcp
Effect of aromatherapy on post-partum complications: A systematic review a
b
c
d
Khadije Rezaie-Keikhaie , Marie Hastings-Tolsma , Salehoddin Bouya , Fahime Shojaei Shad , Mahdieh Sarie, Maryam Shoorvazif,∗, Zeinab Younes Baranie, Abbas Balouchig
T
a
Zabol Medicinal Plants Research Center, Zabol University of Medical Sciences, Zabol, Iran Nurse Midwifery, Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA Clinical Immunology Research Center, Ali-ebne Abitaleb Hospital, Zahedan University of Medical Sciences, Zahedan, Iran d MSC in Nursing, Nursing and Midwifery School, Zabol University of Medical Sciences, Zabol, Iran e Student Research Committee, Nursing and Midwifery School, Zabol University of Medical Sciences, Zabol, Iran f Department of Nursing, School of Nursing, Neyshabur University of Medical Sciences, Neyshabur, Iran g Student Research Committee, Nursing and Midwifery School, Iran University of Medical Sciences, Tehran, Iran b c
ARTICLE INFO
ABSTRACT
Keywords: Aromatherapy Essential oils Post-partum symptoms Systematic review
Introduction: and purpose: Aromatherapy is a known popular method to reduce the symptoms of various physiologic processes and diseases. The aim of the study was to determine whether aromatherapy improves symptoms commonly experienced by women during the postpartum period. Methods: In the present systematic review, four international databases (PubMed, Google Scholar, Web of Science, and Scopus) were searched from inception of databases through August 2018. References for each study were manually reviewed to ensure that relevant works were included. Results: Thirty-four (34) articles were identified with 17 studies meeting eligibility criteria and included a total of 1400 women using a variety of aromatherapies. Results demonstrated that aromatherapy can improve symptoms commonly experienced in post-partum period, including depression, stress, pain, anxiety, and fatigue. Conclusion: There are therapeutic effects in use of aromatherapy during the post-partum period. Aromatherapy, however, should be used with caution as safety concerns have not been conclusively demonstrated.
1. Background The postpartum period is considered as a crucial time associated with various physical and emotional symptoms including pain, impaired sleep quality, stress, anxiety, and fatigue [1–4]. In the postpartum period, more attention is paid to the neonates, and mothers are particularly less evaluated for post-partum symptoms. Screening, diagnosis, and treatment of postpartum symptoms are also essential. The results of studies show that along with treatment of physical symptoms during this period, social support is necessary for improvement of psychological symptoms [5,6]. Various studies indicate that the postpartum period is often associated with having “postpartum blues,” which include temporary transient symptoms, the development of depression and anxiety, as well as feelings of forgetfulness, irritability, headache, and dizziness [7,8]. The prevalence of these symptoms range from 25% to 85% varying in different countries [9–11]. Available treatments for common post-partum symptoms include complementary and alternative therapy approaches - though they often lack evidence for safety and efficacy [12], and complication-specific
∗
pharmacologic therapies [13,14]. Both approaches are designed to minimize postpartum morbidity and mortality and improve quality of life. The use of complementary and alternative therapies has become very popular in recent years [15,16]. Complementary and alternative therapies are popular methods among pregnant women as well. Research from varied countries demonstrate rates of aromatherapy use among pregnant women ranging from 13 to 78% [17]. In addition, studies indicate that most women use at least one complementary therapy during pregnancy [18–20]. Aromatherapy is one complementary and alternative therapy that is very popular considering its ease of use and availability [21]. Aaromatherapy medicinally applies aromatic substances or essential oils to effect health and mood. Essential oils are volatile oils obtained from raw vegetable material through a process of distillation with water or steam, or by dry distillation and are known to have antiseptic, antimicrobial, antiviral, antifungal, and antioxidant properties [22]. Some of the plants used in the creation of essential oils include rosemary, jasmine, rose, tangerine, patchouli, cinnamon, and lavender. Aromatherapy is typically used through topical application or inhalation
Corresponding author. Nursing and Midwifery School, 15 Khordad S, Neyshabur, Iran. E-mail addresses: [email protected], [email protected] (M. Shoorvazi).
https://doi.org/10.1016/j.ctcp.2019.03.010 Received 11 December 2018; Received in revised form 21 February 2019; Accepted 12 March 2019 1744-3881/ © 2019 Elsevier Ltd. All rights reserved.
Complementary Therapies in Clinical Practice 35 (2019) 290–295
K. Rezaie-Keikhaie, et al.
Fig. 1. Study selection process.
symptoms and quality of life. Findings are potentially of use to health professionals and women where efforts are made to reduce symptoms and improve quality of life.
[23]. Topical application through use of massage oils, or bath and skin care products, allows for absorption through the skin. Inhalation allows for oil evaporation into the air through use of a diffuser, spray or droplets, then breathing in the product [22]. When inhaled, the essential oil molecules are sensed by olfactory epithelium and a neural impulse is generated. This neural impulse reaches the olfactory bulb, passes through the olfactory nerve, reaches the limbic region, and stimulates the limbic system of the brain. Essential oils penetrate the skin, enter the bloodstream and the immune system, and release endorphins, improve oxygenation, and nourish cells and tissues, leading to physical and emotional relaxation and a good feeling, because they can have beneficial effects on physiological and psychological processes [24]. Inhaled aromatherapy exerts its effects as physical and mental improvement and stabilization of emotions in persons; these effects can lead to therapeutic effects including reduction in anxiety, depression, pain, spasm, muscle cramp, and fatigue, and improvement of sleep quality [25]. There is a large body of anecdotal evidence regarding the safety and efficacy of essential oils and, while many have been shown to be safe when used as directed, the products are not regulated by the Food and Drug Administration in the United States [26]. Caution is warranted regarding use to minimize possible risks and benefits, particularly in lactating women during the postpartum period where newborn impacts are unknown. Various studies have shown that the aromatherapy is used during pregnancy and postpartum to treat and improve various symptoms such as depression and anxiety, as well as quality of life [12,27,28]. Nevertheless, various studies differ in terms of method, type, amount, and duration of use of varied aromas, and there is a contradiction between results which lead to different results. Therefore, the aim of the present study was to determine the effect of aromatherapy, as an evidence-based, cost-effective and available treatment, on postpartum
2. Methods 2.1. Search strategy Four (4) databases were searched from inception of databases August 2018. These databases included PubMed, Google Scholar, Web of Science, and Scopus. Keywords used included “inhalation aromatherapy” AND “postpartum complication” AND “essential oil” AND “massage aromatherapy.” References for each identified study were manually reviewed to ensure that relevant works were not missed. Inclusion criteria were published, full-length, peer-reviewed studies written in English. The sample population had to comprise postpartum women and use valid and reliable measures to assess outcomes. We excluded abstracts, dissertations and theses, qualitative studies, studies of low methodological quality, and studies where aromatherapy was not the primary focus. Ethical approval was not required for this study since no primary data was being collected. 2.2. Study selection and quality assessment PRISMA guidelines (2009) were used to assess intervention and evaluation studies [29]. Article titles, abstracts and finally full content of the articles were evaluated by two of the researchers (A.B and M.S) to determine the extent to which each article met the inclusion criteria and ensure high inter-rater reliability. Duplicates were removed prior to the analysis. The data extracted included study characteristic (Design, Sample, Quality Assessment), interventions details (time, frequency, 291
Randomized clinical 89 trial PPD 2–10 Randomized control 80 trial PPD 6-8
Behmanesh, F.(2011) [34]
292
Randomized clinical 158 trial PPD 0-8
Randomized clinical trial Randomized clinical trial Randomized clinical trial Quasi-experimental
Randomized clinical 96 trial PPD 0-8
Randomized clinical 96 trial PPD 0-8
Keshavarz Afshar, M. (2015) [44]
Kianpour, M.(2016) [28]
Metawie, M. (2015) [45]
Mirghafourvand, M. (2016) [38]
Mirghafourvand, M. (2017) (25)
140 PPD 105 PPD 35 PPD 100 PPD 0-1
NR
0-6
1-3
36 PPD 2
Vakiliyan, K. (2008) [40] Randomized clinical 120 trial PPD 0-2
Lane, B.(2012) [37]
Kianpour, M.(2018) [36]
Quasi-experimental
Imura, M.(2006) [48]
141 PPD 0-6
Randomized Controlled Trial
Effati-Daryani, F.(2017) [27]
28 PPD 0-18
Pilot study
34 PPD 1-7
Conrad, P.(2012) [43]
Chen, S.L. (2015) [35]
Quasi-experimental one-group
Asazawa, K. (2018) [46]
34 PPD 1-7
Quasi-experimental one-group
Asazawa, K. (2017) [47]
Primary Results
Inhalation aromatherapy lavender
Drink aroma oil Orange
Drink aroma oil Orange
Inhalation aromatherapy using lavender essence oil 10%, 4 drops per session, four times a week before sleeping for 5 min at eight weeks. Inhalation aromatherapy using 3 drops of Lavender scent every day for 4 weeks. Inhalation aromatherapy using 7 drops of Lavender and rose scents every day for 6 weeks. Inhalation aromatherapy using peppermint spirits for between 2 and 5 min. Inhalation aromatherapy using 1 cc of lavender oil via an oxygen facemask, three days per week, for four months. Drink a glass of water containing 10 drops of orange peel essential oil, 3 times a day for eight weeks. Drink a glass of water containing 10 drops of orange peel essential oil, 3 times a day for eight weeks. Bath aromatherapy using 5–10 drops of lavender essence oil twice a day for five days.
Inhalation/Massage Inhalation and massage aromatherapy using 8 aromatherapy lavender and Rose drops blend 2% essential oil of lavender and rose, twice a week, for four weeks. Massage aromatherapy lavender Massage aromatherapy using 2 gr Lavender cream every night 1.5 h before bedtime for six weeks. Massage aromatherapy lavender Massage aromatherapy using 10 drops Lavender and Neroli per 100 ml once for 30 min.
Bath aromatherapy lavender and Bath aromatherapy using 10 drops lavender and olive oil essence oil 10% in five liters of warm water twice a day in ten days. Inhalation/drink aromatherapy Inhalation aromatherapy and ingest a glass of lavender hot water containing 2 gr steeped lavender one a day before bedtime for two weeks.
Quality Assessment Score 1.Scale 2.Score or judgment
Positive effect on episiotomy ulcers
No positive effect on depression and anxiety
Positive effect on sleep quality
Positive effect on post-Caesarean incision pain
Positive effect on stress, anxiety and depression Positive effect on postpartum depression Positive effect on nausea
Positive effect on quality of sleep
(continued on next page)
1.Jadad 2.4
1.Jadad 2.3
1.Jadad 2.5
1.Jadad 2.3 1.Jadad 2.5 1.Jadad 2.5 1.JBI 2.included
1.Jadad 2.4
1.JBI 2.included
1.Jadad 2.4
Positive effect on stress, anxiety, depression, Positive effect on anxiety, maternity blues, mood, and feeling toward baby
1.JBI 2.included
1.Jadad 2.5
1.Jadad 2.3
1.JBI 2.Include
Decrease anxiety and depression.
Positive effect on sleep quality; fatigue (p = 0.01), depression (p = 0.03 and improving maternal infant bonding (p = 0.04)
Positive effect on pain and postpartum healing
Massage aromatherapy lavender, Massage aromatherapy using one of five types of No effect on fatigue; positive effect on ylang-ylang, citron, rosewood, essential aroma oil (pure lavender, ylang-ylang, relaxation and sweet orange citron, rosewood, and sweet orange), Once for 5 min.
Episiotomy ulcers, VAS Bath aromatherapy lavender
Depression and Anxiety, STAI
sleep quality, PSQI
Intervention and dose
Massage aromatherapy lavender, Massage aromatherapy using one of five types of Positive effect on fatigue and relaxation 1.JBI ylang-ylang, citron, rosewood, essential aroma oil (pure lavender, ylang-ylang, where citron and sweet orange used 2.Include and sweet orange citron, rosewood, and sweet orange), Once for (p < 0.05) 5 min.
Type of Aromatherapy 2.dose
Inhalation aromatherapy lavender Inhalation aromatherapy lavender and Rose water Inhalation aromatherapy Peppermint Post Caesarean Incision Inhalation aromatherapy Pain, MJPOM, VAS lavender
Stress, anxiety and depression, DASS-21 Postpartum Depression, HADS Nausea, Nausea Scale
Maternity Blues, STAIAnxiety, POMS Mood, MBS feeling toward baby, FBS quality of sleep, PTSQI
Stress, anxiety and depression, DASS-21
Fatigue, subjective symptoms scale Relaxation, subjective sense of relaxation scale Fatigue, subjective symptoms scale Relaxation, (subjective sense of relaxation scale) Pain, VAS Postpartum healing, REEDA Sleep quality, PSQS Fatigue, EPDS Depression, PFS Improving maternal infant attachment, PBQ Anxiety, EPDS Depression, GAD-7
Sample Size Outcome Measures
Study Design
First Author (Year)
Table 1 Description of the study characteristics, outcome, measurement, interventions and results.
K. Rezaie-Keikhaie, et al.
Complementary Therapies in Clinical Practice 35 (2019) 290–295
Complementary Therapies in Clinical Practice 35 (2019) 290–295
Stress, DASS Prolactin level, ELISA Widyawati, M.(2016) [42]
Key = VAS: Visual Analogue Scale, REEDA: Redness, edema, Ecchymosis, Discharge, Approximation; PSQS: Postpartum Sleep Quality Scale; PFS: Postpartum Fatigue Scale; EPDS: Edinburgh Postnatal Depression Scale; PBQ: Postpartum Bonding Questionnaire; GAD-7: Generalized Anxiety Disorder 7-item; DASS-21: The Depression, Anxiety and Stress Scale - 21 Items; STAI: The State-Trait Anxiety Inventory; POMS: Profile of mood states scale; PTSQI: Pittsburgh Sleep Quality Index; HADS: Hospital Anxiety and Depression Scale; MJPOM: Modified Johanson Pain-O-Meter; ELISA: enzyme-linked immunosorbent assay; PPD: postpartum day.
1.Jadad 2.4 1.Jadad 2.5 Inhalation aromatherapy using 5 drops of No positive effect on episiotomy pain lavender essence oil three times. Inhalation/massage aromatherapy using 3 drops Positive effect on stress, and prolactin of Jasmine, once a week for four weeks. level Inhalation aromatherapy lavender Inhalation/Massage aromatherapy Jasmine Intensity of pain, VAS
Randomized clinical 56 trial PPD 0-2 Randomized clinical 52 trial PPD 7-28 Vaziri, F.(2017) [41]
First Author (Year)
Table 1 (continued)
Study Design
Sample Size Outcome Measures
Type of Aromatherapy 2.dose
Intervention and dose
Primary Results
Quality Assessment Score 1.Scale 2.Score or judgment
K. Rezaie-Keikhaie, et al.
and dose), and results. Quality Assessment of each study was conducted using the Jadad scale whose rating criteria take into account randomization, double blinding, and withdrawals or dropouts [30]. The quality of quasi-experimental studies was assessed using the Joanna Briggs Institute (JBI) quasi-experimental appraisal tool [31]. Each article was independently rated by two of the researchers (K.RK, A, B); disagreements were discussed with third person until consensus was reached. Studies were deemed to be of sufficient quality if they achieved an average score of 3–5 on the JBI instrument [32], and yes answer in 3 of 6 items on the Jadad scale [33]. 3. Results 3.1. Study selection A total of 191 articles were retrieved from the search of databases; 35 from PubMed, 31 from Google Scholar, 14 from Web of Science, and 111 from Scopus. Of the 151 non-duplicated studies in the title and abstract screening process, 117 were excluded because they had unrelated titles and abstracts. Of the remaining 34 studies, 17 met the eligibility criteria. Of the 17 excluded studies, three were review, one was qualitative, six did not have the full text, three were not in English and four did not meet quality requirements for inclusion (see Fig. 1). 3.2. Study characteristics A total of 17 studies that were carried out on 1400 postpartum women entered the final phase. Of these, most of them were clinical trials (n = 12) [12,27,28,34–42]. The sample size across studies ranged from 28 to 158. All studies had low bias risk. Table 1 demonstrates the included studies, design, sample size, measures, type of intervention, primary outcomes, and quality assessment score. 3.3. Main results 3.3.1. Type of interventions Aromatherapy interventions used across studies included inhalation aromatherapy (n = 9) [28,35–37,41–45], aromatherapy massage (n = 6) [27,42,43,46–48], bath with aroma (n = 2) [34,40], and consumption of aroma-containing beverages (n = 2) [38,39]. Interventions were carried out separately or in a combined manner. The aromas examined included lavender (n = 13) [27,28,34–36,40–44,46–48], orange (n = 4) [38,39,46,47], and rose (n = 4) [36,43,46,47]. 3.3.2. Interventions procedures Six studies investigated aromatherapy massage interventions with 3–10 drops used for 5 min to 1.5 h ranging from one day to 6 weeks. In the 9 studies that investigated the various inhalation aromatherapy interventions, 3 to 8 drops were used from 2 to 5 min (three times a day, for one week up to four months). Another four studies investigated other aromatherapies with two studies examining bath use of where 10 lavender drops were added to 5 L of warm water; individuals took a bath twice a day for 10 days. In another intervention, 10 orange aroma drops were dissolved in a glass of warm water and ingested three times a day for 8 weeks. 3.4. Effect of aromatherapy on common postpartum symptoms The 17 studies included in this systematic review investigated the effect of aromatherapy on commonly experienced postpartum symptoms. The most commonly reported symptoms and outcomes included depression (n = 6) [27,28,35,36,39,43], fatigue (n = 3) [35,46,47], and stress (n = 3) [27,28,42]. Reviewing the effect of aromatherapy on postpartum symptoms (outcomes) showed that the aromatherapy had a positive effect on depression (n = 5) [27,28,35,36,43], fatigue (n = 3) [35,46,47], stress (n = 3) [27,28,42], anxiety (n = 2) [27,28], 293
Complementary Therapies in Clinical Practice 35 (2019) 290–295
K. Rezaie-Keikhaie, et al.
relaxation (n = 1) [47], pain (n = 2) [34,45], sleep quality (n = 3) [35,38,44], episiotomy pain (n = 1) [41], postpartum healing (n = 1) [34], nausea (n = 1) [37], prolactin level (n = 1) [42], episiotomy ulcers (n = 1) [40], maternity blues, mood, and feeling toward baby (n = 1) [48], and improving maternal-infant attachment (n = 1) [35]. Aromatherapy use had no significant effect on fatigue, depression or anxiety in one study [39], or on relaxation in another [46]. In order to ensure the safety of aromatherapy, psychiatrists were present along with patients during the intervention in some studies.
postpartum complications. There were also differences in the defined postpartum period with studies ranging from one day to 8 weeks, and postpartum women who had experienced both surgical (i.e., Caesarean, episiotomy) and normal physiologic birth were included and potentially biasing results. Finally, one study (16) examined use of aromas across pregnancy and postpartum periods creating potential bias where treatment was prolonged. Despite the current limitations, this is the first known systematic review that investigates the effects of aromatherapy on common postpartum complications. The promising results should prompt further larger and methodologically sound research.
4. Discussion This is the first known systematic review or meta-analysis specifically investigating the effect of aromatherapy on postpartum symptoms. Work reported here determined the effect of aromatherapy on postpartum symptoms from inception of databases to August 2018. A total of 17 studies were examined and included 1400 women. The aromatherapy interventions in various studies were based on inhalation aromatherapy, aromatherapy massage, bath with aroma, and aroma ingestion (drinking). Findings demonstrate that aromatherapy improves or diminishes commonly experienced postpartum symptoms including depression, fatigue, stress, anxiety, relaxation, pain, sleep quality, episiotomy pain, postpartum healing, nausea, altered prolactin levels, episiotomy ulcers, maternity blues, mood lability, and feelings toward baby. It was interesting to note that lavender was the most commonly used essential oil and likely explains the improvement of the identified post-partum symptoms. Lavendar is known to contain camphor, terpinen-4-ol, linolool, linalyl aetate, beta-ocimene, and 1,8-cineole [23]. These constituents are known to depress the central nervous system, have sedative effects, and marked narcotic-like actions which can reduce anxiety and sleep difficulties, and improve a sense of well-being [23,49,50]. Constituents have also been shown to promote new cell growth, reduce skin problem, reduce painful muscles, and improve immune functioning. There were three studies (25, 27, 32) demonstrating that aromatherapy has no effect on fatigue, pain, depression or anxiety. Asazawa and colleagues (33) conducted a pilot study examining the effect of massage aromatherapy on postpartum fatigue and relaxation and found two massage oils provided significant reduction in fatigue and increased relaxation with use of citron and sweet orange oils (p < 0.05). Study replication found no significant differences. Since no other included study examined use of these particular aromas, further study is warranted, also considering the other aspects of aromatherapy can be help. While several of the studies utilized differences in dosage and methodology, findings from this systematic review are consistent with systematic review studies on the effects of aromatherapy on depression in populations of chronic patients [51], psychological symptoms in post-menopausal women [52], anxiety in chronic patients [24], pain relief in chronic patients [26], depression [53], sleep quality [54], and nausea and vomiting of women during pregnancy [54]. Safety in the present study was confirmed because essential oils were obtained from standard companies. The efficacy and presumed safety of raw materials was further confirmed through pilot use in previous studies of case series [55]. Finally, there were some limitations to the work presented here. The most important limitation of the present study is that while all studies utilized aromatherapy, different aromas were used and at different doses which it is an important barrier to wide use of study results. A few studies failed to give precise details regarding the interventions mentioned making it difficult to analyze the works with greater rigor. These differences made it impossible to conduct a meta-analysis to more precisely determine the effect of aromas on postpartum symptoms. Additionally, several of the studies had small sample sizes with failure to report power calculations. Both nulligravid and multigravid women were included with potentially different experiences of common
5. Conclusion Results from this systemic review demonstrate that aromatherapy is effective as an inexpensive, easy-to-use, fast-acting, and holistic method to improve common postpartum symptoms such as nausea, postpartum blues, depression, and mood lability, as well as anxiety, stress, fatigue, pain – including episiotomy pain, and episiotomy ulcers. Further, aromatherapy improves postpartum relaxation, sleep quality, healing, prolactin levels, and feelings toward the baby. Despite the great benefits of aromatherapy in the postpartum period, the perfumes should be used with caution and after evaluating their safety due to the mentioned limitations. Given the limited number of articles in this area, further studies are also suggested into the effects of aromatherapy on pregnant women. Authors’ contribution Khadije Rezaie-Keikhaie and Maryam Shoorvazi: study design and conceptualization; Maryam Shoorvazi, Zeinab Younes Barani and Fahime Shojaei Shad: Search strategy and data collection; Mahdieh Sari and Abbas Balouchi: data analysis and interpretation; Marie HastingsTolsma, Khadije Rezaie-Keikhaie, Abbas Balouchi, and Salehoddin Bouya: manuscript writing; Marie Hastings-Tolsma, Khadije RezaieKeikhaie, Maryam Shoorvaz: study supervision. Financial conflicts of interest None declared. Funding/support None declared. Acknowledgments The author wishes to thank the nursing research center and the deputy of research and technology at Zabol University of Medical Sciences. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ctcp.2019.03.010. References [1] P. Berens, Overview of the Postpartum Period: Physiology, Complications, and Maternal Care, (2018). [2] O. Stephansson, A. Sandström, G. Petersson, A.K. Wikström, S. Cnattingius, Prolonged second stage of labour, maternal infectious disease, urinary retention and other complications in the early postpartum period, BJOG An Int. J. Obstet. Gynaecol. 123 (4) (2016) 608–616. [3] B.W. Prick, D. Bijlenga, A.G. Jansen, K.E. Boers, S.A. Scherjon, C.M. Koopmans, M.G. van Pampus, M.-L. Essink-Bot, D.J. van Rhenen, B.W. Mol, Determinants of health-related quality of life in the postpartum period after obstetric complications, Eur. J. Obstet. Gynecol. Reprod. Biol. 185 (2015) 88–95.
294
Complementary Therapies in Clinical Practice 35 (2019) 290–295
K. Rezaie-Keikhaie, et al.
[30] H.D. Clark, G.A. Wells, C. Huët, F.A. McAlister, L.R. Salmi, D. Fergusson, A. Laupacis, Assessing the quality of randomized trials: reliability of the Jadad scale, Contr. Clin. Trials 20 (5) (1999) 448–452. [31] C. Tufanaru, Z. Munn, E. Aromataris, J. Campbell, L. H (Eds.), Systematic Reviews of Effectiveness, 2017 (Chapter 3), https://reviewersmanual.joannabriggs.org/. [32] C. Tufanaru, Z. Munn, E. Aromataris, J. Campbell, L. H, Chapter 3: systematic reviews of effectiveness, in: E. Aromataris, Z. Munn (Eds.), Joanna Briggs Institute Reviewer's Manual. 2017 https://reviewersmanual.joannabriggs.org. [33] A.R. Jadad, R.A. Moore, D. Carroll, C. Jenkinson, D.J. Reynolds, D.J. Gavaghan, H.J. McQuay, Assessing the quality of reports of randomized clinical trials: is blinding necessary? Contr. Clin. Trials 17 (1) (1996) 1–12. [34] F. Behmanesh, M. Tofighi, M.A. Delavar, M. Zeinalzadeh, A.A. Moghadamnia, S. Khafri, A clinical trial to compare the effectiveness of lavender essential oil and olive oil at healing postpartum mother's perinea, HealthMED 5 (6) (2011) 1512–1516. [35] S.L. Chen, C.H. Chen, Effects of lavender tea on fatigue, depression, and maternalinfant attachment in sleep-disturbed postnatal women, Worldviews Evidence-Based Nurs. 12 (6) (2015) 370–379. [36] M. Kianpour, F. Moshirenia, G. Kheirabadi, G. Asghari, A. Dehghani, A. DehghaniTafti, The effects of inhalation aromatherapy with rose and lavender at week 38 and postpartum period on postpartum depression in high-risk women referred to selected health centers of Yazd, Iran in 2015, Iran. J. Nurs. Midwifery Res. 23 (5) (2018) 395–401. [37] B. Lane, K. Cannella, C. Bowen, D. Copelan, G. Nteff, K. Barnes, M. Poudevigne, J. Lawson, Examination of the effectiveness of peppermint aromatherapy on nausea in women post C-section, J. Holist. Nurs. : Off. J. Am. Holistic Nurses' Assoc. 30 (2) (2012) 90–104 quiz 105-6. [38] M. Mirghafourvand, S.M.A. Charandabi, S. Hakimi, L. Khodaie, M. Galeshi, Effect of orange peel essential oil on postpartum sleep quality: a randomized controlled clinical trial, Eur. J. Integr. Med. 8 (1) (2016) 62–66. [39] M. Mirghafourvand, S.M.A. Charandabi, S. Hakimi, L. Khodaie, M. Galeshi, The effect of orange peel essential oil on postpartum depression and anxiety: a randomized controlled clinical trial, Iran. Red Crescent Med. J. 19 (2) (2017). [40] K. Vakilian, M. Atarha, The effect of lavender in care of postpartum episiotomy wounds, J. Shahrekord Univ. Med. Sci. 10 (2008). [41] F. Vaziri, M. Shiravani, F.S. Najib, S. Pourahmad, A. Salehi, Z. Yazdanpanahi, Effect of lavender oil aroma in the early hours of postpartum period on maternal pains, fatigue, and mood: a randomized clinical trial, Int. J. Prev. Med. 8 (2017) 29. [42] M.N. Widyawati, S. Hadisaputro, A. Anies, A. Soejoenoes, Effect of massage and aromatherapy on stress and prolactin level among primiparous puerperal mothers in Semarang, central Java, Indonesia, Belitung Nursing Journal 2 (4) (2016). [43] P. Conrad, C. Adams, The effects of clinical aromatherapy for anxiety and depression in the high risk postpartum woman - a pilot study, Complement. Ther. Clin. Pract. 18 (3) (2012) 164–168. [44] M. Keshavarz Afshar, Z.B. Moghadam, Z. Taghizadeh, R. Bekhradi, A. Montazeri, P. Mokhtari, Lavender fragrance essential oil and the quality of sleep in postpartum women, Iran. Red Crescent Med. J. 17 (4) (2015) 1–7. [45] M.A.-H. Metawie, H. Amasha, R.A. Abdraboo, S.E. Ali, Effectiveness of aromatherapy with lavender oil in relieving post Caesarean Incision pain, J. Surg. 3 (2–1) (2015) 8–13. [46] K. Asazawa, Y. Kato, R. Koinuma, N. Takemoto, S. Tsutsui, Effectiveness of aromatherapy treatment in alleviating fatigue and promoting relaxation of mothers during the early postpartum periaod, Open J. Nurs. 8 (03) (2018) 196. [47] K. Asazawa, Y. Kato, A. Yamaguchi, A. Inoue, The effect of aromatherapy treatment on fatigue and relaxation for mothers during the early puerperal period in Japan: a pilot study, Int. J. Commun. Based Nurs. Midwifery 5 (4) (2017) 365–375. [48] M. Imura, The psychological effects of aromatherapy-massage in healthy postpartum mothers, J. Midwifery Women's Health 51 (2) (2006) e21–e27. [49] S. Kim, H.-J. Kim, J.-S. Yeo, S.-J. Hong, J.-M. Lee, Y. Jeon, The effect of lavender oil on stress, bispectral index values, and needle insertion pain in volunteers, J. Altern. Complement. Med. 17 (9) (2011) 823–826. [50] P.H. Koulivand, M. Khaleghi Ghadiri, A. Gorji, Lavender and the nervous system, evid.-based complement, Altern. Med. 2013 (2013). [51] V. Yim, A.K. Ng, H.W. Tsang, A.Y. Leung, A review on the effects of aromatherapy for patients with depressive symptoms, J. Altern. Complement. Med. 15 (2) (2009) 187–195. [52] M. Babakhanian, M. Ghazanfarpour, L. Kargarfard, N. Roozbeh, L. Darvish, T. Khadivzadeh, F.R. Dizavandi, Effect of aromatherapy on the treatment of psychological symptoms in postmenopausal and elderly women: a systematic review and meta-analysis, J. Menopausal Med. 24 (2) (2018) 127–132. [53] D.I. Sánchez-Vidaña, S.P.-C. Ngai, W. He, J.K.-W. Chow, B.W.-M. Lau, H.W.H. Tsang, The effectiveness of aromatherapy for depressive symptoms: a systematic review, Evid.-Based Complement, Altern. Med. 2017 (2017). [54] E. Hwang, S. Shin, The effects of aromatherapy on sleep improvement: a systematic literature review and meta-analysis, J. Altern. Complement. Med. 21 (2) (2015) 61–68. [55] T. Dunning, Aromatherapy: overview, safety and quality issues, OA Altern. Med. 1 (1) (2013) 6.
[4] X. Liu, E. Agerbo, J. Li, S. Meltzer-Brody, V. Bergink, T. Munk-Olsen, Depression and anxiety in the postpartum period and risk of bipolar disorder: a Danish nationwide register-based cohort study, J. Clin. Psychiatry 78 (5) (2017) e469–e476. [5] I. Brockington, Postpartum psychiatric disorders, Lancet 363 (9405) (2004) 303–310. [6] D.K. Gjerdingen, K.M. Chaloner, The relationship of women's postpartum mental health to employment, childbirth, and social support, J. Fam. Pract. 38 (5) (1994) 465–473. [7] S. Seth, A.J. Lewis, M. Galbally, Perinatal maternal depression and cortisol function in pregnancy and the postpartum period: a systematic literature review, BMC Pregnancy Childbirth 16 (1) (2016) 124. [8] A.R. Gobinath, R.J. Richardson, C. Chow, J.L. Workman, S.E. Lieblich, A.M. Barr, L.A. Galea, Voluntary running influences the efficacy of fluoxetine in a model of postpartum depression, Neuropharmacology 128 (2018) 106–118. [9] P. Vigano, L. Corti, N. Berlanda, Beyond infertility: obstetrical and postpartum complications associated with endometriosis and adenomyosis, Fertil. Steril. 104 (4) (2015) 802–812. [10] D. Ehrmann Feldman, É. Vinet, M.-P. Sylvestre, B. Hazel, C. Duffy, A. Bérard, G. Meshefedjian, S. Bernatsky, Postpartum complications in new mothers with juvenile idiopathic arthritis: a population-based cohort study, Rheumatology 56 (8) (2017) 1378–1385. [11] E. Kang, R. Sugarman, H. Ramadan, A. Mueller, S. Shahul, J.L. Perdigao, D.J. Louis, R. Narcisse, H. Sannon, L. Magee, Prevalence, risk factors and associated complications of postpartum hypertension in rural Haiti, Pregnancy hypertension 10 (2017) 135–142. [12] M.K. Afshar, Z.B. Moghadam, Z. Taghizadeh, R. Bekhradi, A. Montazeri, P. Mokhtari, Lavender fragrance essential oil and the quality of sleep in postpartum women, Iran. Red Crescent Med. J. 17 (4) (2015). [13] A.D. Mackeen, R.E. Packard, E. Ota, L. Speer, Antibiotic regimens for postpartum endometritis, Cochrane Database Syst. Rev. (2) (2015). [14] B. Shulman, R. Dueck, D. Ryan, G. Breau, I. Sadowski, S. Misri, Feasibility of a mindfulness-based cognitive therapy group intervention as an adjunctive treatment for postpartum depression and anxiety, J. Affect. Disord. 235 (2018) 61–67. [15] S. Bouya, S. Ahmadidarehsima, M. Badakhsh, A. Balouchi, Effect of Aromatherapy Interventions on Hemodialysis Complications: A Systematic Review, Complementary Therapies in Clinical Practice, (2018). [16] A. Balouchi, G. Mahmoudirad, M. Hastings-Tolsma, S.A. Shorofi, H. Shahdadi, A. Abdollahimohammad, Knowledge, Attitude and Use of Complementary and Alternative Medicine Among Nurses: A Systematic Review, Complementary Therapies in Clinical Practice, (2018). [17] H.G. Hall, D.L. Griffiths, L.G. McKenna, The use of complementary and alternative medicine by pregnant women: a literature review, Midwifery 27 (6) (2011) 817–824. [18] L. Gaffney, C.A. Smith, The Views of Pregnant Women towards the Use of Complementary Therapies and Medicines, (2004). [19] C.O. Ong, L.Y. Chan, P.B. Yung, T.N. Leung, Use of traditional Chinese herbal medicine during pregnancy: a prospective survey, Acta Obstet. Gynecol. Scand. 84 (7) (2005) 699–700. [20] H. Skouteris, E.H. Wertheim, S. Rallis, S.J. Paxton, L. Kelly, J. Milgrom, Use of complementary and alternative medicines by a sample of Australian women during pregnancy, Aust. N. Z. J. Obstet. Gynaecol. 48 (4) (2008) 384–390. [21] A. Balouchi, M. Rahnama, M. Hastings-Tolsma, M.M. Shoja, E. Bolaydehyi, Knowledge, attitude and use of complementary and integrative health strategies: a preliminary survey of Iranian nurses, J. Integr. Med. 14 (2) (2016) 121–127. [22] C. Nordqvist, Aromatherapy: what you need to know, https://www. medicalnewstoday.com/articles/10884.php, (2017) , Accessed date: 21 February 2019. [23] B. Ali, N.A. Al-Wabel, S. Shams, A. Ahamad, S.A. Khan, F. Anwar, Essential oils used in aromatherapy: a systemic review, Asian Pac. J. Trop. Biomed. 5 (8) (2015) 601–611. [24] Y.-L. Lee, Y. Wu, H.W. Tsang, A.Y. Leung, W. Cheung, A systematic review on the anxiolytic effects of aromatherapy in people with anxiety symptoms, J. Altern. Complement. Med. 17 (2) (2011) 101–108. [25] M.J. Kim, E.S. Nam, S.I. Paik, The effects of aromatherapy on pain, depression, and life satisfaction of arthritis patients, J. Korean Acad. Nurs. 35 (1) (2005) 186–194. [26] S.E. Lakhan, H. Sheafer, D. Tepper, The Effectiveness of Aromatherapy in Reducing Pain: a Systematic Review and Meta-Analysis, Pain Research and Treatment 2016, (2016). [27] F. Effati Daryani, S.M.A. Charandabi, S. Zarei, A. Mohammadi, M. Mirghafourvand, Effect of lavender cream with or without footbath on anxiety, stress and depression of women in postpartum: a clinical randomized controlled trial, Iran, J. Obstet. Gynaecol. India 20 (10) (2017) 52–61. [28] M. Kianpour, A. Mansouri, T. Mehrabi, G. Asghari, Effect of lavender scent inhalation on prevention of stress, anxiety and depression in the postpartum period, Iran. J. Nurs. Midwifery Res. 21 (2) (2016) 197–201. [29] D. Moher, A. Liberati, J. Tetzlaff, D.G. Altman, Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement, PLoS Med. 6 (7) (2009) e1000097.
295